Domain Name and Hosting application Form

  1. These services are supplied to you under a TWELVE (12) MONTH CONTRACT, by submitting this application you agree to be bound by the terms and conditions of this contract, please refer to the online documentation, (see Hosting and or Domain Name Registrations) and our Acceptable Use Policy (AUP).
  2. Once this application is submitted to us CHARGES WILL BE INCURRED, this application can not be cancelled without payment of relevant fees.
  3. You must accept the terms and conditions at the bottom of this agreement by ensuring you place a tick in the box. The application can not be processed with out this.

Terms are strictly payment in advance. (payments must be made prior to the 1st of each month).
Payment must be supplied with this request form in order for us to accept and process it.
If you are paying by electronic funds transfer (EFT / pay anyone etc) the application will held until your payment is received.

If an application for service is not successful a full refund will be provided.

Registrant Name
 NOTE: The Registrant field must be a person, company or incorporated association, you cannot put trusts, trading names or partnerships as the registrant. For more information Click Here
Registrant ID Type
Registrant ID ACN/ABN ONLY
Eligibility Type
Trading as (optional)

(check box if domain based on trading name)

Trading Name

BRN (Business number) State

Claim Type
Close and substantial connection:
If you are making a claim for the domain based on a "close and substantial connection" to your business, please provide details.
Trademark claim:
If you are making a claim for the domain based on a registered trademark, please provide details

Trademark Name

Trademark Number

Title

Your First name*
Your Surname *
Sub-address type E.G. Level
Sub-address number E.G 8
Street number * E.G 250
Street name * E.G St Georges
Street type * E.G Tce
Street suffix E.G West
Suburb/State *
Post Code *
Home telephone *
Work telephone *
Fax
Mobile
Your e-mail address* (For correspondence only)
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Domain Name You require

Domain Name* Extention*

Is this a new domain name registration or

Does your domain name already exits and simply require redeligation

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Requested service type

Hosting Service Type Required Preferred Payment period

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Do you require additional e-mail addresses or mailboxes Please click here to complete the required form
Do you require hit statistics for your web site / domain
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Payment Method
Cheque, Cash or Money Order
EFT (Electronic Funds Transfer)

Please make payable to West Australian Networks and post to:
PO Box 532 HILLARYS WA 6923 or pay over the counter at any branch of the National Australia Bank . You will need the bank details on the right
  • Account Name: The Emery Corporation P/L T/AS West Australian Networks
  • BSB Number: 086495 Account Number: 691499751
  • Please ensure you mark the deposit with your full name to enable accounts dept to identify it.
When paying via cheque / cash / money order / or EFT the application will be held pending receipt of your payment for the setup fee and one (1) month connection.
Credit Card
Card Type
Credit Card Number
Expiry Date
Name On Card
*AMEX Security number
 For Amex cards you need the 4 digit ID code found on the right had side just above the card number.
By completing and submitting this form I authorise West Australian Networks to debit my nominated credit card (above) for any valid charges incurred by the use of this service.

Your comments

Please reply to my comments

I hereby certify that I am authorised to sign the contract and instruct WA Networks to provide the service requested.

I have read, understand & agree to be bound by the Terms & conditions of this application including the Acceptable Use Policy (AUP)*
 

NOTE: If you receive an error message reading: "The form was not submitted for the following reasons: You are coming from an unauthorized domain. Please use your browser's back button to return to the form and try again".

This problem is caused by your personal firewall blocking HTTP referrer information (cookies) which the script checks as a security measure. When that information is blocked by your firewall software, the form returns the error message you received.

To send the form, you can temporarily disable your firewall (which you should be able to do by right-clicking its icon in the system tray* and selecting the option to disable it), and then try submitting the form again. Once you submit the form, go back to the system tray icon and right-click again to turn the firewall back on.

We are sorry for the inconvenience, but in this age of hackers, spammers, and worms, we are trying to protect our site from abuse.

IF YOU STILL HAVE PROBLEMS, Please email us cag@westnet.net.au